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UNF IEDP OGRM CONSOLIDATED F M <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> Page of <br /> TYPE OF ACTION r 1.NEW SITE PERMIT r 3.RENEWAL PERMIT r 5.CHANGE OF INFORMATION(Speay change- .PERMANENTLY CLOSED SITE <br /> (Check one item only) r 4.AMENDED PERMIT tical use only) r S.TANK REMOVED 400 <br /> r 6.TEMPORARY SITE CLOSURE <br /> I.FACILITY I SITE INFORMATION <br /> BUSINESS NAME(Same se FACILITY NAME or DBA-Doing Business As) 3 FACILITY IDI <br /> NEARES CROSS I EET 401 FACILITY OWNER TYPE ]'4. LOCAL AGENCYIDISTRICT- <br /> r S C, F 1. CORPORATION r 5. COUNTY AGENCY` <br /> SU <br /> SINESS TYPE r 1.GAS STATION r 3.FARM r 5.COMMERCIAL ^ INDIVIDUAL r & STATE AGENCY' <br /> F 2.DISTRIBUTOR r 4.PROCESSOR >(6.OTHER r 3. PARTNERSHIP r 7. FEDERAL AGENCY- 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS la facility on Indian Reaervetion or 'B owner of UST is a public agency.name of supervisor of <br /> REMAINING AT SITE wstlands? division,section or office which operates Pre UST. <br /> (This is the coated person for the tank records.) <br /> 404 r Yea xo 405 406 <br /> It.PROPERTY OWNER INFORMATION <br /> PROPERTY ONMER NAME C64, 7 � PHONE 408 <br /> MAILI G RSTREET ADDRESS <br /> /✓ll/I <br /> CITY �4 ��aV ✓,/`r�10 TATE I/ 4F11IP CODE 472 <br /> L/ 01,56? <br /> PROPERTY OWNER TYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATEAGENCY 413 <br /> r 1. CORPORATION r 3. PARTNERSHIP r 5. COUNTYAGENCY r 7. FEDERAL AGENCY <br /> Ill.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> J q--)� <br /> MAILING OR STREET ADDRESS 415 <br /> CITY 417 TATE 418 21P CODE 419 <br /> TANK OWNERTYPE INDIVIDUAL r 4. LOCALAGENCY/DISTRICT r 6. STATE AGENCY 420 <br /> F 1. CORPORATION ]" 3. PARTNERSHIP r 5. COUNTY AGENCY r 7. FEDERALAGENCY <br /> 'V DIAIDOEEQIIAIIZATInNiiqTSTnRAr�FFFFArratiNTNilrARPR <br /> TY(TK)HO 4 4 - Call(916)322-9669 if questions arise 421 <br /> 11 PFTRnIFIIAAIjATFI <br /> INDICATE METHOD(S) r 1. SELF-INSURED r 4. SURETY BOND r 7. STATE FUND r to. LOCAL GOV=T MECHANISM <br /> F 2 GUARANTEE r 5. LETTER OF CREDIT r 8 STATE FUND S CFO LETTER r 99 OTHER <br /> - <br /> F 3. INSURANCE r S. EXEMPTION r 9. STATE FUND&CD 422 <br /> nnRFR <br /> Check one box to indicate which address should be used for legal rxNi 'ons end mailing. r 1. FACILITY . PROPERTY OWNER r 3. TANK OWNER 423 <br /> Local D li na end m will the tank unless 1 or is chanAtid. <br /> Certification'. 1 certify that the information provided herein is true and a curste to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424 PHONE 425 <br /> NAME OF APPLICANT(prim) 426 TITLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER(For kxxN use cal428 1998 UPGRADE CERTIFICATE NUMBER(ForlocaluseoMy) 429 <br /> a3 /��/ <br /> UPCF(1199 revised) 6 5-36 - 0 ✓ '�� Formerly SWRCB Form A <br /> �PBd <br />